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Pharyngitis

Pharyngitides

Pharyngitis is defined as an infection or inflammation of the pharynx which is common in children.


Presentation

Symptoms usually vary depending on whether it is a viral or bacterial infection. They may also vary from mild to severe.

In case of viral pharyngitis, the symptoms include the following:

Patients suffering from bacterial pharyngitis usually present with the following features:

  • Fever
  • Body ache
  • Generalized body sickness
  • Enlarged tonsils with white spots
  • Swollen, tender lymph nodes in front of the neck
  • Edema, erythema and lymphoid hyperplasia may also be present.

Children usually present with diarrhea, loss of appetite, conjunctivitis, cough, and fever as high as 105 F [5]. In severe cases, there may be dysphagia for fluids and even for saliva [6].

Patients with fungal infections present with oral thrush in most of the cases.

Cervical Lymphadenopathy
  • One of the most commonly used scoring system is the Centor Score , assigning points for tonsillar exudates, tender anterior cervical lymphadenopathy, absence of cough and history of fever.[rhdaction.org]
  • Posterior cervical lymphadenopathy is common in patients with infectious mononucleosis, and its absence makes the diagnosis much less likely.[aafp.org]
  • She had an intact airway with moderate trismus and mild anterior cervical lymphadenopathy. She was afebrile. Computed tomography ( Figure 1 ) and radiography ( Figure 2 ) were performed. Figure 1. Figure 2.[aafp.org]
  • On clinical examination, patients with group A strep pharyngitis usually have Pharyngeal and tonsillar erythema Tonsillar hypertrophy with or without exudates Palatal petechiae Anterior cervical lymphadenopathy Patients with group A strep pharyngitis[cdc.gov]
  • Diagnosis Diagnosis of diphtheria includes observation of a pseudomembrane and bleeding upon removal of the membrane and severe cervical lymphadenopathy.[atsu.edu]
Pharyngitis
  • Pharyngitis can be viral or bacterial. The most common and clinically significant bacterial cause of acute pharyngitis are group A beta-hemolytic streptococci. Pharyngitis is the inflammation of the throat (pharynx).[symptoma.com]
  • Prevalence estimates for GAS ve pharyngitis, serologically-confirmed GAS pharyngitis and asymptomatic pharyngeal carriage were generated. Findings were stratified by age group, recruitment method and country income level.[ncbi.nlm.nih.gov]
  • Group A streptococcus (GAS) is the most common bacterial etiology of pharyngitis but is difficult to distinguish clinically from viral pharyngitis.[ncbi.nlm.nih.gov]
  • However, when recurrent pharyngitis takes place within 40 days after completing the treatment, alternative drugs should be considered for retreatment because the pharyngitis is likely to be due to reactivation.[ncbi.nlm.nih.gov]
Sore Throat
  • A total of 101 patients with sore throat were tested with 26 (25.7%) positive for GAS. One hundred and forty-seven patients without sore throat were tested with one positive POC test result (specificity 99%; 95% CI 96-100).[ncbi.nlm.nih.gov]
  • Throat , Sore Throats , Throat, Sore , THROAT SORE , [D]Throat pain , [D]Throat pain (context-dependent category) , Sore throat symptom NOS , [D]Throat discomfort , throat pain (symptom) , sore throat (symptom) , sore throat , throat pain , sore throat[fpnotebook.com]
  • The focus of this article will be on sore throat caused by viruses and bacteria since these are the most common causes of sore throat. 20 Sore Throat Home Remedies There are a variety of home remedies that can be used to help soothe a sore throat.[medicinenet.com]
Cough
  • […] spaces Using correct coughing and sneezing technique, such as coughing or sneezing into a tissue and disposing it, or into the inner side of the upper arm Do not share food or drinks with infected individuals Regularly clean the sleeping and living areas[dovemed.com]
  • Hallmarked by acute onset of sore throat; the absence of cough, nasal congestion and discharge suggests a bacterial aetiology. Rapid antigen detection tests allow immediate point-of-care assessment of group A Streptococcus (GAS) pharyngitis.[bestpractice.bmj.com]
  • Other common symptoms include fever, swollen lymph nodes in the neck, cough, headache, pain in the ears and hoarseness. The treatment depends on the cause.[symptoma.com]
  • This is why it is common for a person with pharyngitis to also have a cough, runny nose, nasal congestion, hoarseness, and/or redness or irritation of the eyes ( pink eye ).[flu.emedtv.com]
  • They include: measles adenovirus, which is one of the causes of the common cold chickenpox croup , which is a childhood illness distinguished by a barking cough whooping cough group A streptococcus Viruses are the most common cause of sore throats.[healthline.com]
Stridor
  • Symptoms include a “barking” cough, stridor, hoarseness, and potentially dyspnea. Anteroposterior radiography may show subglottic narrowing (steeple sign). A peritonsillar abscess may lead to similar symptoms as retropharyngeal abscess.[aafp.org]
  • This may progress to inspiratory stridor and labored breathing. There may be signs of chest retraction and on auscultation of the chest there may be decreased breath sounds, wheezing, or prolonged inspiration or expiration.[emedmd.com]
  • If stridor is present, consider a foreign body or epiglottitis. If the patient is drooling, the patient may be in severe pain, or consider a foreign body or epiglottitis. If the voice is abnormal, consider several processes.[cdemcurriculum.com]
  • CME expires 12/1/2020 • Management of Airway Obstruction and Stridor in Pediatric Patients Nov 2017 This issue discusses the most common as well as the life-threatening etiologies of acute and chronic stridor and its management in the emergency department[ebmedicine.net]
  • Airway obstruction can occur, and findings of tachypnea, stridor, and cyanosis are seen.[atsu.edu]
Throat Irritation
  • Breathing through your mouth — often because of chronic nasal congestion — also can cause a dry, sore throat. Irritants. Outdoor air pollution can cause ongoing throat irritation.[mayoclinic.org]
  • A person who strains their voice when yelling or speaking for long periods of time may complain of a sore throat. Irritation can also be due to gastro-esophageal reflux, dry heat or pollutants and chemicals such as tobacco smoke.[antimicrobe.org]
Fever
  • Acute rheumatic fever is currently rare in the United States.[accessmedicine.mhmedical.com]
  • Periodic fever, aphthosis, pharyngitis, and adenitis (PFAPA) syndrome is a periodic fever syndrome of childhood with an unknown etiology.[ncbi.nlm.nih.gov]
  • Don’t give your child aspirin to relieve a fever. Using aspirin to treat a fever in children could cause a serious condition called Reye syndrome. Give your child cool liquids to drink.[fairview.org]
  • However, the bacteria can still be present with little or no fever.[clinicaladvisor.com]
  • Other common symptoms include fever, swollen lymph nodes in the neck, cough, headache, pain in the ears and hoarseness. The treatment depends on the cause.[symptoma.com]
Chills
  • In addition to a sore, dry, or scratchy throat , a cold or flu may cause: sneezing runny nose headache cough fatigue body aches chills fever (a low-grade fever with a cold and higher-grade fever with the flu) In addition to a sore throat, the symptoms[healthline.com]
  • A 27-year-old woman complains of 2 days of sore throat, fever, and chills. She is unable to swallow anything other than liquids because of severe odynophagia. She denies any congestion or cough.[accessmedicine.mhmedical.com]
  • If pharyngitis is caused by the common cold then symptoms will include: Cough Sneezing Headache Raised temperature (mild) Pharyngitis as part of influenza (or ‘the flu’) will include the following symptoms: Aches and pains Fever Chills Extreme tiredness[medic8.com]
  • […] lymph glands in the neck Depending on what illness is causing the sore throat, symptoms can vary, as in the following: Sore throat with cold: Sneezing Cough A low fever (less than 102 degrees F) Mild headache Sore throat with flu: Fatigue Body aches Chills[everydayhealth.com]
Turkish
  • The differences between patients from the Turkish and US cohorts may be due to epigenetic or environmental factors.[ncbi.nlm.nih.gov]
Tonsillar Exudate
  • Based on the presence of fever, absence of cough, tender lymphadenopathy, and tonsillar exudate, she is diagnosed with a high probability of group A β-hemolytic Streptococcus (GABHS) pharyngitis and prescribed antibiotics.[accessmedicine.mhmedical.com]
  • exudate with or without scarlatiniform rash, fever and malaise had been subjected to perform a rapid test (RAD: Rapid antigen detection) for the search of the beta-hemolytic Streptococcus Group A (GABHS).[ncbi.nlm.nih.gov]
  • The original model designated four criteria: tonsillar exudates, swollen tender anterior cervical nodes, absence of a cough, and history of fever.[mdcalc.com]
  • The strongest independent predictors of GABHS pharyngitis are patient age of five to 15 years, absence of cough, tender anterior cervical adenopathy, tonsillar exudates, and fever.[aafp.org]
  • One of the most commonly used scoring system is the Centor Score , assigning points for tonsillar exudates, tender anterior cervical lymphadenopathy, absence of cough and history of fever.[rhdaction.org]
Palatal Petechiae
  • On clinical examination, patients with group A strep pharyngitis usually have Pharyngeal and tonsillar erythema Tonsillar hypertrophy with or without exudates Palatal petechiae Anterior cervical lymphadenopathy Patients with group A strep pharyngitis[cdc.gov]
  • Palatal petechiae and thick white/purple exudate can often be present. Splenomegaly and/or hepatomegaly can be present in more than 50% of patients.[infectiousdiseaseadvisor.com]
  • Physical examination includes the following: Assessment of airway patency Temperature Hydration status Head, ears, eyes, nose, and throat – Conjunctivitis, scleral icterus, rhinorrhea, tonsillopharyngeal/palatal petechiae, tonsillopharyngeal exudate,[emedicine.medscape.com]
Halitosis
  • Chronic tonsillitis is less well defined but may present with chronic sore throat, halitosis, malaise, and coughing up of cryptic debris.[emedmd.com]
Erythema
  • The erythema is particularly concentrated in the axillary area. ( Courtesy of Richard P. Usatine, MD .)[accessmedicine.mhmedical.com]
  • […] the following objectives: (1) Getting the answer to an unmet medical need; (2) Promoting the appropriateness of the use of antibiotics; (3) Provide a means of containment in pharmaceutical spending. 50 patients presenting sore throat associated with erythema[ncbi.nlm.nih.gov]
  • The pharynx should be examined for erythema, hypertrophy, foreign body, exudates, masses, petechiae, and adenopathy. It also is important to assess the patient for fever, rash, cervical adenopathy, and coryza.[aafp.org]
  • Abdominal pain Runny nose Patients suffering from bacterial pharyngitis usually present with the following features: Fever Body ache Generalized body sickness Enlarged tonsils with white spots Swollen, tender lymph nodes in front of the neck Edema, erythema[symptoma.com]
  • EER causes laryngeal and pharyngeal erythema with edema of the vocal cords and false vocal cords, larynx, and pharynx.[emedmd.com]
Headache
  • They cause fever, headache, and sore throat that last for 4 to 14 days. Lymphatic tissue in the pharynx may also become involved.[britannica.com]
  • Take paracetamol, ibuprofen or aspirin to ease any pain and other symptoms such as a headache. Do NOT give aspirin to children under 16.[medic8.com]
  • Sore throat with flu: Fatigue Body aches Chills Fever higher than 102 degrees F Sore throat with mononucleosis: Enlarged lymph nodes in neck and armpits Swollen tonsils Headache Loss of appetite Swollen spleen Liver inflammation Diagnosis of Pharyngitis[everydayhealth.com]
  • In patients from Turkey, symptom onset was at a younger age, fever attacks were of shorter duration, and pharyngitis was more frequent, whereas adenitis, headache, and nausea/vomiting were less frequent during attacks, when compared to patients from the[ncbi.nlm.nih.gov]
Neglect
  • This has resulted in a significant cost savings in pharmaceutical expenditure, without neglecting the more important and correct application of the Guidelines with performing of a clinically validated test that carries advantages for reducing the use[ncbi.nlm.nih.gov]

Workup

A complete history with thorough examination of the mouth, throat, nose, ears and lymph nodes in front of the neck is necessary. It is hard to differentiate between a viral and bacterial cause based on symptoms alone; however, Centor criteria is helpful in the diagnosis of streptococcal pharyngitis [7] [8].

The following investigations are necessary to establish the diagnosis.

  • White blood cell (WBC) count will be raised with predominance of polymorphs.
  • Throat culture is the primary method for the diagnosis of streptococcal pharyngitis and the most reliable means of differentiating streptococcal from viral pharyngitis.
  • Non-specific tests such as erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) are of very little importance [9].

Treatment

The majority of time treatment is symptomatic. Specific treatments are effective for bacterial, viral and fungal infections.

Medications

Antibiotics: The treatment of choice for streptococcal pharyngitis is oral penicillin V (250mg) given 3 times daily for 10 days. This is helpful if bacterial infection is the cause of sore throat [10]. Antibiotics have no effect for a viral infection. Non-compliant patients may be given a single intramuscular injection of benzathine penicillin G, which provides adequate penicillin levels for 10 days. The usual dose is 600,000 units for children weighing less than 25 kg and 1,200,000 units for children weighing 25 kg or more.

Penicillin-allergic patients may be given any of the several alternative antibiotics:

  • Oral erythromycin (50 mg/kg/day in three divided doses for 10 days). Or
  • Oral cephalosporins such as cephradin or cephalexin (50-100 mg/kg/day in three divided doses for 10 days). Or
  • Oral clarithromycin (15 mg/kg/day in two divided doses for 10 days).

If the patient has had three or more documented infections within 6 months, consider daily penicillin prophylaxis during the winter season.

Analgesics: They help reduce soreness of the throat. Most effective analgesics include non-steroidal anti-inflammatory drugs and acetaminophen.

Steroids: They are helpful in severe pharyngitis. Dexamethasone is often used for this purpose.

Idocaine: It helps to relieve pain by numbing the mucous membrane.

Surgery

Surgery should be considered when the patients have frequent episodes of pharyngitis or when the persistently enlarged tonsils cause chronic upper airway obstruction.

Prognosis

Almost all the people with viral and bacterial streptococcal pharyngitis recover completely without complications; so the overall the prognosis is excellent. Streptococcal infection of the throat should always be treated carefully as untreated cases may develop rheumatic fever [4].

Etiology

There can be infectious or non-infectious causes of pharyngitis.

Infectious

Acute pharyngitis is an oropharyngeal infection. The disease most commonly spreads via contact with infected individuals and droplet infection. The infectious agents may be bacterial, viral or fungal in nature [1].

Viral: These comprise about 40-60% of all the infectious cases. The different kinds of viruses include:

Bacterial: The different kinds of bacteria include:

  • Streptococci: Group A beta-hemolytic streptococc are the most common bacterial cause of acute pharyngitis. Common symptoms include fever, sore throat and large lymph nodes.
  • Fusobacterium necrophorum: These organism are normal inhabitants of oropharyngeal flora. However, they may cause peritonsillar abscess in some cases [2].
  • Diphtheria: This is a life threatening upper respiratory infection caused by Corynebacteria diphtheria.

Fungal: Sometimes, the oral thrush caused by Candida albicans may extend to involve the pharynx.

Non-infectious

Non-infectious cases of acute pharyngitis result from mechanical, chemical or thermal irritation including cold air or acid reflux. Neoplastic conditions can also cause pharyngitis [3].

Epidemiology

Streptococcal pharyngitis is one of the most common respiratory infections of the childhood. The disease is uncommon under the age of 1 year. The peak incidence occurs in children between the age of 5 and 15 years. Pharyngitis in children younger than 2 years of age is often viral. The incidence is higher in the winter and early spring. It is estimated that it affects more than 1.9 million people a year.

Sex distribution
Age distribution

Pathophysiology

Etiologic agents may directly invade or cause irritation to the pharyngeal mucosa, resulting in localized inflammatory reaction or cause secondary irritation.

Prevention

The following are the known ways of preventing pharyngitis.

  • Frequent washing of the hands.
  • Avoidance of the sharing of eating utensils or cups with anyone who has a sore throat, flu, common cold or bacterial infection.
  • Avoiding both active and passive smoking.
  • Using a humidifier if the surrounding air is dry.
  • Using vitamin C supplements may also be helpful as it improves components of human immune system such as natural killer cell activity.
  • Supplementation of zinc may also be essential as it may be involved directly in antibody production to help you fight infections.

Summary

Pharyngitis is the inflammation of the pharynx commonly caused by upper airway infection. The disease can be acute or chronic. In most of the cases, it is quite painful and results in enlarging of the tonsils which cause trouble in swallowing or even in breathing. Due to systemic infection, it may also be associated with cough and fever. Pharyngitis can be viral or bacterial. The most common and clinically significant bacterial cause of acute pharyngitis are group A beta-hemolytic streptococci.

Patient Information

Pharyngitis is the inflammation of the throat (pharynx). Pharyngitis is most often caused by viruses, but can also result from bacterial infection. The main symptom is a dry and sore throat. Other common symptoms include fever, swollen lymph nodes in the neck, cough, headache, pain in the ears and hoarseness. The treatment depends on the cause.

References

Article

  1. Mostov PD. Treating the immunocompetent patient who presents with an upper respiratory infection: pharyngitis, sinusitis, and bronchitis. Primary care. Mar 2007;34(1):39-58.
  2. Kushawaha A, Popalzai M, El-Charabaty E, Mobarakai N. Lemierre's syndrome, reemergence of a forgotten disease: a case report. Cases journal. 2009;2:6397.
  3. Alcaide ML, Bisno AL. Pharyngitis and epiglottitis. Infectious disease clinics of North America. Jun 2007;21(2):449-469, vii.
  4. Gerber MA, Baltimore RS, Eaton CB, et al. Prevention of rheumatic fever and diagnosis and treatment of acute Streptococcal pharyngitis: a scientific statement from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee of the Council on Cardiovascular Disease in the Young, the Interdisciplinary Council on Functional Genomics and Translational Biology, and the Interdisciplinary Council on Quality of Care and Outcomes Research: endorsed by the American Academy of Pediatrics. Circulation. Mar 24 2009;119(11):1541-1551.
  5. Gerber MA. Diagnosis and treatment of pharyngitis in children. Pediatric clinics of North America. Jun 2005;52(3):729-747, vi.
  6. Shaikh N, Swaminathan N, Hooper EG. Accuracy and precision of the signs and symptoms of streptococcal pharyngitis in children: a systematic review. The Journal of pediatrics. Mar 2012;160(3):487-493 e483.
  7. Wagner FP, Mathiason MA. Using centor criteria to diagnose streptococcal pharyngitis. The Nurse practitioner. Sep 2008;33(9):10-12.
  8. Centor RM, Allison JJ, Cohen SJ. Pharyngitis management: defining the controversy. Journal of general internal medicine. Jan 2007;22(1):127-130.
  9. Group ESTG, Pelucchi C, Grigoryan L, et al. Guideline for the management of acute sore throat. Clinical microbiology and infection : the official publication of the European Society of Clinical Microbiology and Infectious Diseases. Apr 2012;18 Suppl 1:1-28.
  10. Del Mar CB, Glasziou PP, Spinks AB. Antibiotics for sore throat. The Cochrane database of systematic reviews. 2006(4):CD000023.

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